On July 28, 2022, over 10” of heavy rains overnight created flash flooding in eastern Kentucky, leading to the deadliest flood in state history.1, Reference Childress, Estep and Honeycute Spears2 Nearly 600 homes were destroyed with thousands severely damaged.3 Over 600 people were displaced in emergency shelters, state parks, and travel trailers.3
Sudden, unexpected displacement, as caused by natural disasters, from one’s home can cause profound effects on physical and mental health as well as one’s ability to receive health messaging and access basic necessities.4, 5, 6 Damage to property, loss of shelter, and the impacts of water damage can last well beyond the immediate stages of disaster response.6 Damage to powerlines, loss of access to broadband internet, and inability to use transportation may lead to devastating loss in access to communication and community.4 The number of natural disasters is anticipated to rise, making it imperative to understand the needs of communities impacted by disasters in order to best prepare for the future.7
With the goal of understanding the needs of affected families post-initial disaster response, we surveyed households living in flood evacuation shelters 6weeks after the 2022 eastern Kentucky floods. There were 5 key topic areas we wanted to understand through the survey: 1) household experiences during the flood, 2) household repair status, 3) communication and messaging at their shelter site, 4) household recovery status and needs, and 5) physical and behavioral impacts.
Methods
Kentucky Department for Public Health and local health department leadership developed a survey instrument with CDC subject matter experts. The final questionnaire included household demographics, when families evacuated their home, families’ access to internet, transportation, and cellular service, housing status, communications, recovery status after the flood, physical health status, mental health status and needs, and individual-level mental health status that included the 2 item Patient Health Questionnaire (PHQ-2) and 2 item Generalized Anxiety Questionnaire (GAD-2). The questionnaire was 2 pages and took about 20 minutes to administer (Appendix I). In this paper, we describe the findings of these sub-topics as well as considerations for actions that may improve the status of these flood-impacted communities and households.
Prior to conducting interviews, a just-in-time training occurred. At these trainings, volunteers were trained on the overall purpose of the questionnaires, content of the questionnaires, interview techniques, safety, what to do if there is a serious mental health concern, and logistics. All volunteer teams conducting surveys consisted of at least 1member of the public health departments from affected counties in eastern Kentucky. Teams were provided with informational material on public health needs (e.g., mold clean up, suicide hotlines, local public health resources) that could be provided to all potential respondents.
Families experiencing displacement from the 2022 eastern Kentucky floods currently living in 3 different temporary shelter locations (which included sheltering in travel trailers, campers, rooms, cottages, and campgrounds) were surveyed. Data were collected 6 weeks after the floods, over the course of 4 days during September 6-9, 2022. These emergency shelters included lodging at state resort park cabins and RV parks (Jenny Wiley State Resort Park (“Jenny Wiley”), Buckhorn Lake State Resort Park (“Buckhorn”), and Mine Maid Adventure Park (“Mine Maid"). The local health departments contacted the emergency shelters to let them know the days teams were coming to conduct the survey.
Convenience sampling was used to enroll participants to capture the experience of as many families living in the shelters as possible. This consisted of volunteers knocking on doors and soliciting participation over 4 days. Participation was completely voluntary. Three shelters in different areas of eastern Kentucky were chosen to ensure the sample was as representative of the affected population and their needs as possible. Interview participants were required to be aged ≥18 years and living in regions effected by the floods prior to being displaced in shelters. One representative for each family unit housed at the shelter was invited to represent that household unit in the survey. The families displaced will be referred to as “households” throughout this paper.
Results
A total of 150 families who were displaced from the flood were still living in the 3 shelter sites during the survey week: 80 families at Jenny Wiley; 41 families at Buckhorn; and 29 families in trailers at Mine Made. A total of 61 (40.6%) families were surveyed. Of these, 52.5% were living at Jenny Wiley, 23.0% at Buckhorn, and 24.6% at Mine Maid (Table 1). Prior to the flood, approximately half of shelter site residents owned their homes while the other half were renters. When asked when they evacuated their households (before, during, or after the flood), less than 20% of households reported evacuating before (11.5%), or after (18.0%) the flood, with most households reporting evacuation during the actual flooding event (70.5%). Most households in these shelter sites had family members between the ages of 2-64 years, with roughly a quarter of households (27.9%) reporting household members aged ≥65 years and <5% reporting children aged <2 years.
Table 1. Shelter sites household demographics — KY Flooding 2022
* Households could identify more than 1response.
Household Experiences Since the Flood
At the time of the survey, 6 weeks after the flooding event, nearly half of households at shelter sites reported no internet service (46.7%) and 20.0% reported not having access to transportation or cellular service (Table 2). When asked how close their home is to being how it was prior to floods (excluding landscape), 72.4% of households reported their home was not repaired at all. Nearly a quarter of households reported the availability of contractors/skilled labor (23.0%) and finding materials/supplies (24.6%) were barriers to their home being repaired, and 21.3% reported insufficient money.Footnote 1 When asked if they would be willing to relocate outside of the floodplain if their household had an offer to sell, 42.6% of households reported they would be willing and 11.5% reported “maybe.” Approximately a quarter (26.7%) of shelter site households reported none of the debris and waste had been removed from their property and almost 40% of households reported some debris and waste and been removed (38.3%). Nearly 15% of shelter site households (12.1%) indicated they did not have a 7-day supply of prescription medications.
Table 2. Shelter sites household experiences and utilities/services during the recent flood — KY Flooding 2022
* Households could identify more than 1 response.
Communications
Most households at shelter sites reported having no warning of the flood (85.3%); half (50.8%) reported seeing rising water as their first warning sign of the flood; nearly a third heard from friends/family (32.8%); 16.4% received a phone weather alert; and about 10% received warning of the flood through social media, television, and/or internet news (Table 3). When participants were asked if any member of their household had difficulty prior to the flood accessing the radio, television, internet, or cell for communication, 37.7% reported no difficulties. However, almost 30% of households reported having difficulty receiving communication through the internet, nearly a quarter reported difficulty with television (24.6%), and approximately 20% reported having difficulty with cellular service (19.7%) and radio (21.3%).
Table 3. Shelter sites household flood warning and communication — KY Flooding 2022
* Households could identify more than 1response.
Households living in shelter sites were asked, since the flood, what, if any health and clean up messages their household heard. Approximately 40% reported hearing messages about mold clean-up and disaster recovery centers, 16.4% about vaccinations, and 27.9% reported not hearing any clean up or health messaging (Table 4). When asked how their household heard messaging about health and/or clean-up, 45.9% reported hearing messaging from friends with only a small percentage of households reporting health and/or clean-up messaging from other sources such as TV, radio, church/place of worship, public health department, internet news, social media, or flyer/poster.
Table 4. Shelter sites household messaging regarding health and/or clean-up — KY Flooding 2022
* Households could identify more than 1response.
** Other includes FEMA, insurance providers, heard information at lodge, and from park rangers.
Home Clean-Up and Assistance
Households living at shelter sites were asked what stage of home clean-up their family’s home was in currently. Half (50.9%) reported their home was destroyed and they can’t live there again. When asked if anyone in their household had attempted to receive assistance related to the floods, 67.4% reported receiving assistance from churches, 57.4% from family/friends, 38.5% from non-profit organizations, 34.4% from Red Cross, and 33.3% from local government.
Regarding assistance from FEMA, 32.8% reported their household attempted to receive assistance from FEMA, and of that group, 62.3% of those reported receiving funds from FEMA. For those who received FEMA assistance, they were asked how difficult it was to get assistance, with 28.1% saying it was “very difficult” and 38.6% saying it was “difficult,” or nearly 70% indicating difficulty. If assistance was received, households were asked if the assistance covered the financial costs needed for the home: 78.2% said “no.” Some of the top barriers to receiving assistance included the documentation/paperwork process being difficult and confusing to navigate (25.0%), issues with FEMA such as attitude of FEMA personnel and documentation (9.3%), and FEMA not paying enough (3.1%).
Access to Professional Medical Care
Households living at shelter sites were asked if it’s been more difficult to get needed professional medical care for any member of their household since the flood, and 15.3% reported more difficulty receiving usual medical care. Households were also asked if it has been difficult to get needed prescriptions; 18.3% said “yes.” When asked if it had been more difficult to get needed medical supplies, 18.6% said “yes.” Since the flood, 41.4% reported their household experienced a worsening of allergies, 35.6% reported experiencing a worsening of high blood pressure, 32.1% worsening overall health, 31.0% a worsening of asthma, and 22.4% a worsening of COPD.
Stressors and Behavioral Health Needs
Households at shelter sites were asked, since the flood, how often would you say your household was worried or stressed about having enough money. Approximately a quarter of households reported they were always (22.0%) or sometimes worried or stressed about having enough money to pay bills (25.4%). When asked about meals, 22.0% of households reported they were always and sometimes worried or stressed about having enough money for meals. Regarding rent, 13.6% of households at shelter sites reported they were always and 18.6% of households reported sometimes being worried or stressed about paying rent.
Of households living at shelter sites, 27.7% reported they received services for behavioral or mental health (18.0% from a therapist) and 19.6% received grief counseling (Table 5). When asked about barriers to seeking services for behavioral health concerns, 36.1% reported no difficulty accessing, or no need for counseling services. However, some barriers to receiving counseling services noted were transportation (11.5%) and being unaware of resources (8.2%). When asked how they or their household would like to receive behavioral health assistance, 57.4% reported they would like to receive it locally and 39.3% reported they would like telehealth.
Table 5. Shelter sites household source of behavioral and mental health services — KY Flooding 2022
* Households could identify more than 1response.
Households living at shelters sites were asked if they or members of their household had experienced any of several different mental health indicators since the flood (Table 6). Households indicated they or some member of their household had experienced nightmares (62.3%), difficulty concentrating (47.5%), loss of appetite (36.1%), agitation (36.7%), witnessed violent behavior or threats (9.8%), or suicidal thoughts/self-harm (6.6%).
Table 6. Shelter sites household stressors and behavioral health needs since the flood — KY Flooding 2022
Individuals surveyed were asked of themselves only, how often over the past 2 weeks they felt down, depressed, or hopeless? Over half (55.4%) reported either “several days” (28.6%) or “nearly every day” (26.8%), and 7.1% reported “more than half the days.” Participants were asked over the last 2 weeks how often they had little interest or pleasure in doing things; 23% reported “several days” and 21.3% reported “nearly every day.” Participants were also asked over the last 2 weeks how often they felt nervous, anxious, or on edge: 44.1% reported “several days” and 23.7% reported “nearly every day.” These questions originated from the PHQ2. Finally, they were asked over the last 2 weeks, how often had they been unable to stop or control worrying with 35.6% reporting “several days” and 33.9% reporting “nearly every day.” These questions originated from the GAD-2. Approximately a third of participants (36.1%) reported their mental health was “not good,” which includes, stress, depression, and problems with emotions for at least half the days or more out of the past 30 days.
Discussion
Six weeks after the floods, we surveyed approximately 40% of families who were currently displaced from their homes and living at 3 shelter sites — Jenny Wiley, Buckhorn, and Mine Maid. Families living at shelter sites were displaced from their homes and represented the community members hardest hit by this flood event in eastern Kentucky. Half of households at shelter sites had their homes destroyed and were no longer livable, and nearly 75% of households’ homes had not been repaired at all, being located in some of the worst flood-affected areas in eastern Kentucky. During the flood, most households living at shelter sites evacuated their homes during the flood, had no warning, or were warned primarily by seeing the water rise. Although some households were warned of the flood by phone weather alert, very few received warning from the television, radio, or social media. These findings reveal a need for increased and targeted communication prior to another public health event or natural disaster to increase community preparedness levels, promote better education about evacuation procedures, and decrease potential loss of life and resources.
Many households living at shelter sites reported difficulty accessing the internet, television, cell service, and radio for communication messaging; limiting access of these highly impacted households to useful recovery resources. Although many households heard messaging about mold clean up and disaster recovery centers, over a quarter of households heard no health or clean up messaging. The top communication source for how households heard warnings about the flood or rising water was by word of mouth, followed by social media (although minimally).
Our study provides unique experiences of communities living in shelters in rural areas after the deadliest floods in Kentucky history. This work represents experiences of 61 families living in shelters 6 weeks after flooding, which may provide different perspectives as compared to some of the existing literature on individuals’ experiences in shelters,Reference Milburn, McNeill and Clay8 flooding in non-rural areas,Reference Ermagun, Smith and Janatabadi9, Reference Escobar Carías, Johnston and Knott10 work representing a smaller number of people surveyed,Reference Ponnambily11 or lessons learned pieces.Reference Wu, Huang and Pang12, Reference Kuang and Liao13
Improving Communication and Messaging
These findings reveal the need to assure there are adequate communication modalities quickly made available in family shelter settings to improve access to health and clean-up messaging. This should include first making available or improving broadband service, as well as targeting radio, television, and written communication for consumption of shelter residents to increase the capacity for relaying important information that will allow households to communicate and receive messages more effectively. Expanding this to community-level activity may also increase preparedness levels prior to another public health emergency, as communities will be better equipped to receive targeted messaging and communication.
Challenges in receiving messaging from sources such as the internet, cellular services, or broadband internet during disasters in rural communities make it imperative to think strategically about effective communication.Reference Graves, Abshire and Amiri14, 15 While larger structural changes are needed, such as increasing access to broadband in rural communities, it will also be important to think about technology disparities in ability to access computers and smart phones that differentially impact rural communities.15, 16 Using non-electronic forms of communication such as written materials and messaging from trusted community members may be a critical and more effective means of disseminating important information before, during, and after natural disasters.17, 18
Improving Access to Housing Assistance and Logistical Resources
Churches, FEMA, Red Cross, family, friends, and non-profit organizations provided some of the main sources of ongoing assistance to households living at shelter sites after the flood. Some of the main barriers households reported to receiving assistance included difficulty navigating the paperwork process and transportation. Providing more financial, organizational, and logistical resources to connect sources of support to families living at shelter sites may improve their short and long-term recovery conditions.19 On a larger scale, a key component to disaster preparedness is a need for adequate resources to support preparedness efforts, which includes support for planning, housing resource centers, staffing, trainings, exercising preparedness plans, and improving technical assistance for disaster relief.19
Improving Access to Physical and Mental Health Services
Households living at shelter sites experienced worse overall health and physical health conditions than before the flood event, such as allergies, asthma, high blood pressure, and COPD. Additionally, many households experienced worsened emotional and mental health conditions like nightmares, difficulty concentrating, agitation, and loss of appetite. Individuals also reported recent feelings of depression, anxiety, and overall problems with mental health. While some households at shelter sites reported seeking behavioral health services and grief counseling, primarily from a licensed therapist, there was also a higher preference for counseling in-person and locally if mental health assistance was ever needed, followed by telehealth.
These findings show a need for access and availability to physical and mental/behavioral health services for household members living at shelter sites. Planning for surge capacity and assuring that mental health resources are available and accessible for families in shelters soon after disaster events is recommended to address the concerns raised by this survey. Targeted social media campaigns, educational resources, and efforts made through trusted sources like churches, non-profit organizations, and schools are avenues to address overall health (including mental health) in disaster situations19 for families with no recourse other than shelter living for extended periods.
Improving access to communication and messaging, housing assistance and logistical resources, and physical and mental health resources are all avenues to ensure communities are prepared to respond and recover from disasters. Partnership and efforts from the Kentucky Department for Public Health and community partners from Pathways, Mountain Comprehensive Care Center, and University of the Cumberlands were integral in conducting the work described in this paper. These results may be used to help improve future communication messaging, promote the public’s health, and strengthen preparedness capacity of eastern Kentucky as well as other rural communities. This work may inform insights into allocating resources for future flooding events and evaluating and implementing best practices for communication, resources, and physical, and mental health services in disaster shelter settings.
Limitations
The data generated from the shelter sites are only a snapshot in time and are not representative of all households displaced from the flood, which should be considered when interpreting the results of the ongoing recovery efforts. Interview teams were only able to conduct interviews for 4 days and could not survey as many households using this convenience sample methodology. These results are self-reported by 1 (or more) individual(s) representing an entire household; therefore, results may be biased, as the interviewee may not be aware of everything about each household member they are representing.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/dmp.2024.136.
Funding statement
There are no funding sources to disclose.
